multi-drug resistant tuberculosis - tb-ipcp.co.za 2 16 march... · smear negative mdr-tb patients...

Multi-Drug Resistant

Tuberculosis

A Policy Framework on Decentralised and Deinstitutionalised Management in South Africa

Dr. Norbert Ndjeka

Director, Drug-Resistant TB, TB and HIV

Outline

1. Introduction: historical background and

purpose of the policy framework

2. Elements of decentralised MDR-TB care

3. Structure, levels and functions

4. Conclusions & recommendations

3/15/2012 2 Dr. Norbert Ndjeka

INTRODUCTION

3/15/2012 Dr. Norbert Ndjeka 3

Historical background

July ‘09

• First workshop on community-based MDR-TB at Kopanong Hotel, Johannesburg, facilitators Drs. Jaramillo & Nkhoma

Oct ‘09

• Workshop on best practices and community MDR-TB. Facilitators: Drs. Bayona & Alcantra

May ‘10

• Discussion and adoption of the decentralised MDR-TB approach by TB Managers during quarterly meeting

Jun ‘10 • Circulated draft policy framework on decentralised management of MDR-TB

Nov ‘10

• National MDR-TB workshop to plan implementation

May ’11

• Final draft discussed by Technical Committee at NHC meeting

26 Aug ’11

• Approval

Oct ‘11 • Printing


Purpose of the Policy Framework

Provides guidance for management of MDR-TB patients closer to their homes, both in health facilities and in community

Enables provinces to start MDR-TB treatment as soon as diagnosis is made, hence decreasing risk of transmission


South Africa

Globally, every year, an estimated 0.5 million patients develop MDR-TB

South Africa is among the high burden TB and MDR-TB countries worldwide

In 2010 we diagnosed: 7 386 MDR-TB patients 741 XDR-TB patients

Success rate of MDR-TB is low 42% (2007 cohort), 48 % (2008 cohort)

Number of beds available: ~2500 beds


RSA Treatment Outcome 2003-

2008 (Sensitive TB)

0

10

20

30

40

50

60

70

80

90

2003 2004 2005 2006 2007 2008

Rx Success Rate Cure rate Defaulter rate

7 Dr Norbert Ndjeka

MDR-TB outcomes, 2007 (n=3334)

Province Rx

Success (%)

Failure (%)

Defaulted (%)

Died (%) T/Out

(%) Still on Rx (%)

HIV +ve (%)

EC 10 10 2 21 15 41 44

FS 42 8 24 21 6 0 47

GP 19 2 7 17 6 49 50

KZN 71 1 7 16 0 5 0

LP 38 3 23 31 6 0 52

MP 57 10 1 32 0 0 37

NC 19 6 16 44 2 13 18

NW 66 2 6 19 7 0 0

WC 35 9 29 23 3 3 33

Total 42 5 10 20 5 18 25


Treatment Outcomes, 2008


Province

# started on

treatment

Treatment

Success Rate

% TSR Died % Died

Failed Defaulted

Not Evaluat

ed

EC 683 216 32 197 29 94 93 83

FS 165 70 42 44 27 9 32 10

GP 367 165 45 67 18 11 86 38

KZN 1717 1069 62 222 13 77 167 182

LP 103 61 59 25 24 3 14 0

MP 278 133 48 68 24 19 56 2

NC 142 35 25 45 32 34 28 0

NW 146 115 79 22 15 4 5 0

WC 782 232 30 166 21 56 282 43

RSA 4383 2096 48 856 20 307 763 358

10

Limpopo

North West Gauteng Mpumalanga

Kwa-Zulu Natal Free State

Northern Cape

Western Cape

Eastern Cape

• 24 M(X)DR Units

• ~2,500 Beds

MDR-TB Units in South Africa

MDR-TB Units before 2009

Decentralised MDR-TB Units after 2009

Dr. Norbert Ndjeka 3/15/2012

Laboratory diagnosed MDR-TB


MDR-TB cases started on

treatment, 2007-2010

0

200

400

600

800

1000

1200

1400

1600

1800

2000

EC FS GP KZN LP MP NC NW WC

2007

2008

2009

2010


Patient Load and Bed Availability

(as of April 2011)


MDR-TB case finding and number

put on treatment

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

2004 2005 2006 2007 2008 2009 2010

Lab Diagnosed

Started Treatment


Challenges

Nearly half of diagnosed cases are not started on treatment

1-2 months of waiting for admission, sometimes more

Long distance of transportation for admission and follow up

Negative impact on social and economic status of the individual and family due to a long stay in hospital

Risk of transmission in hospital due to inadequate implementation of infection control measures

Non-uniformity in current, sporadic efforts of decentralized management

Issues of refusal to admission and aggressive demand for early discharge

Poor outcome of DR-TB cases


Benefits of Decentralisation

Ease the burden on the health system

Reduce transmission of DR-TB by initiating treatment sooner

Make more beds available

Improve patient adherence to medication

Improve cost effectiveness (i.e., reduce lengthy hospital stays in specialised hospitals

Accommodate patient roles and responsibilities by treating them closer to home


ELEMENTS OF DECENTRALISED MDR-TB CARE


Requirements for decentralised

MDR-TB care (1)

Prompt and accurate MDR-TB diagnosis Trained multidisciplinary team with adequate

and effective mentorship and supervision Guidelines/protocols for clinical management Uninterrupted supply of second-line anti-TB

drugs Adequate infrastructure and infection control

measures Integration with local TB programme activities

as well as HIV and PHC


Requirements for decentralised

MDR-TB care (2)

Selection of patients to receive treatment in community and defaulter tracing mechanism

Communication between different levels of health care, including effective Advocacy, Communication and Social Mobilisation

Rigorous monitoring and evaluation: Indicators are defined and operational research may be conducted

Ring-fenced resources dedicated to providing specialised MDR-TB staff


STRUCTURES, LEVELS AND FUNCTIONS


Levels for the Decentralised

Management of DR-TB


Responsibilities at every level

Functions Provincial/Central-ised MDR-TB unit

Decentralised MDR-TB unit

Satellite MDR-TB unit

Mobile team Community Supporters

Initiation of treatment of all DR-TB cases

√ √ NO NO NO

Admission of all MDR-TB cases till two successive smear negative

√ √

No, unless no bed at Prov. or dec. unit

NO NO

Admission of all XDR-TB cases till two successive culture negative

√ NO NO NO NO

Monthly follow up of all DR-TB cases attending at clinic

√ √ √ √ NO

DOT to all DR-TB patients attending daily

√ √ √ √ √

Recording and reporting (R & R) to the provincial department of health

√ √ NO NO NO

Monitoring and supervising DR-TB clinical management in the province

√ NO NO NO NO


Minimum staffing requirements

Staff Provincial/

Centralised MDR-TB unit



Mobile team

Doctor 1/40 beds 1/40 beds if occupancy is > 75%

P/T optional 0

Professional nurse/ Staff nurse or Nursing Assistant

4/11 per 40 beds 4/ 11 per 40 beds 1 for 20 beds 1 for 20 patients

Pharmacist 1 per 100 - 200 beds

P/T 1 for 10- 20 patients

0 0

Social worker 1 for > 40 beds P/T for 10- 20 patients

P/T optional 0

Dietician 1 for > 40 beds P/T for 10- 20 patients

0 0

Clinical Psychologist 1 for > 40 beds P/T for 10- 20 patients

0 0

Occupational Therapist

1 for > 40 beds P/T for 10- 20 patients

0 0


Minimum staffing level

Staff Provincial/

Centralised MDR-TB unit



Mobile team

Audiologist 1 for > 100 beds P/T 1 for 20- 40

patients 0 0

Physiotherapist 1 for > 40 beds P/T 1 for 10- 20

patients 0 0

Data Capturer/ Admin Clerk

1 for 100- 200 beds P/T 1 for 10- 20

patients P/T optional 0

Driver 1 for > 40 beds 0 0 1 for 20 patients

Community Health Care Worker

0 0 1 for 10 patients 1 for 10 patients


Infection control at home & in the

community

Ventilation/open windows

Isolation of patient (ideally own bed room)

Cough hygiene

Refrain from close contact with children

Maximise time in open-air environment

(e.g., receive visitors outside)

Minimise contact with known HIV positive patients


Roles and

Responsibilities

Partnership MRC-Johns Hopkins

Conduct research and training

WHO

Technical assistance

TB/HIV Care

Support implementation of decentralised management of MDR-TB services

MSF

Support implementation of decentralised management of MDR-TB services

URC,CDC & USAID

Funding a number of activities supporting decentralisation of MDR-TB services

CSIR

Mapping MDR-TB patients

Help improve TB Infection Control

Eli Lilly

Funding MDR-TB activities (training and research)

NDOH

Coordination of decentralisation and deinstitutionalisation of MDR-TB services

PROVINCIAL TB SERVICES

Implementation of decentralised and deinstitutionalised management of MDR-TB services

FPD

Training

Philanjalo

Facilitate implementation plans for decentralised and deinstitutionalised management of MDR-TB at district level


CONCLUSION &

RECOMMENDATIONS


Conclusions & recommendations

Smear negative MDR-TB patients in good general condition and who can access treatment near their homes may be started on treatment on an out-patient basis

All smear-positive MDR-TB patients should be admitted until the get TWO negative TB smears

Very sick MDR-TB patients (extensive resistance patterns, pulmonary cavitations, MDR-TB re-treatments), XDR-TB patients and those with no access to decentralised or satellite MDR-TB units must be admitted until they achieve TB culture conversion



Flow

of D

R-T

B P

atie

nts

PHC Facility Mobile Teams

Decentralised Site

Centralised DR-TB Unit

Monitoring and Evaluation


Screening # of smear microscopy tests, etc # of patients screened

Average TAT for lab tests Sputum microscopy Cultures and DST

Drug supply Any drug shortages (quarterly)

Integration with HIV services # of patients with known HIV status # tested during quarter # of positive tests per quarter # patients on ART

Treatment Outcomes Cured, completed, defaulted, died or transferred

Patient load

# of DR-TB beds

# of DR-TB patients admitted

# of DR-TB patients treated as

outpatients

# of DR-TB patients discharged

(per month)

# of patients treated by mobile

teams

WHAT SHOULD DECENTRALISED

MANAGEMENT ACHIEVE?

Not for dumping patients to lower levels

Early detection of MDR TB cases

Early treatment initiation

Better utilization of existing personnel, (nurses to initiate MDR treatment)

Better retention & reduction in loss to follow up (defaulters), reduced mortality

Improved clinical management that yield better outcomes (Conversion, Cure)

31

ACKNOWLEDGEMENTS

DR. LORNA NSHUTI

MS. HELEN SAVVAH


Thank you


multi-drug resistant tuberculosis - tb-ipcp.co.za 2 16 march... · smear negative mdr-tb patients...

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